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Wu PH, Hung SK, Ko CA, Chang CP, Hsiao CT, Chung JY, Kou HW, Chen WH, Hsieh CH, Ku KH, Wu KH. Performance of Six Clinical Physiological Scoring Systems in Predicting In-Hospital Mortality in Elderly and Very Elderly Patients with Acute Upper Gastrointestinal Bleeding in Emergency Department. Medicina (B Aires) 2023; 59:medicina59030556. [PMID: 36984556 PMCID: PMC10057917 DOI: 10.3390/medicina59030556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated and compared with in-hospital mortality. Results: A total of 336 patients were recruited, of whom 40 died. There is a significant difference between the patients in the mortality group and survival group in terms of the six scoring systems. MEWS had the highest area under the curve (AUC) value (0.82). A subgroup analysis was performed for a total of 180 very elderly patients (i.e., older than 75 years), of whom 27 died. MEWS also had the best predictive performance in this subgroup (AUC, 0.82). Conclusions: This simple, rapid, and obtainable-by-the-bed parameter could assist emergency physicians in risk stratification and decision making for this vulnerable group.
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Affiliation(s)
- Po-Han Wu
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Shang-Kai Hung
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Chien-An Ko
- Department of Otorhinolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
- Department of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan
| | - Jui-Yuan Chung
- Department of Emergency Medicine, Cathay General Hospital, Taipei City 106, Taiwan
| | - Hao-Wei Kou
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Wan-Hsuan Chen
- Department of Pediatric, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Chiao-Hsuan Hsieh
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
| | - Kai-Hsiang Ku
- Department of Emergency Medicine, Sijhih Cathay General Hospital, New Taipei City 221, Taiwan
- Correspondence: (K.-H.K.); (K.-H.W.)
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County 613, Taiwan
- Correspondence: (K.-H.K.); (K.-H.W.)
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Benedeto-Stojanov D, Bjelaković M, Stojanov D, Aleksovski B. Prediction of in-hospital mortality after acute upper gastrointestinal bleeding: cross-validation of several risk scoring systems. J Int Med Res 2022; 50:3000605221086442. [PMID: 35301889 PMCID: PMC8943321 DOI: 10.1177/03000605221086442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We aimed to identify the clinical, biochemical, and endoscopic features associated with in-hospital mortality after acute upper gastrointestinal bleeding (AUGIB), focusing on cross-validation of the Glasgow-Blatchford score (GBS), full Rockall score (RS), and Cedars-Sinai Medical Center Predictive Index (CSMCPI) scoring systems. METHODS Our prospective cross-sectional study included 156 patients with AUGIB. Several statistical approaches were used to assess the predictive accuracy of the scoring systems. RESULTS All three scoring systems were able to accurately predict in-hospital mortality (area under the receiver operating characteristic curve [AUC] > 0.9); however, the multiple logistic model separated the presence of hemodynamic instability (state of shock) and the CSMCPI as the only significant predictive risk factors. In compliance with the overall results, the CSMCPI was consistently found to be superior to the other two systems (highest AUC, highest sensitivity and specificity, highest positive and negative predictive values, highest positive likelihood ratio, lowest negative likelihood ratio, and 1-unit increase in CSMCPI associated with 6.3 times higher odds of mortality), outperforming the GBS and full RS. CONCLUSIONS We suggest consideration of the CSMCPI as a readily available and reliable tool for accurately predicting in-hospital mortality after AUGIB, thus providing an essential backbone in clinical decision-making.
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Affiliation(s)
| | - Milica Bjelaković
- Clinic of Gastroenterology and Hepatology, Clinical Center Niš, 18000 Niš, Serbia
| | | | - Boris Aleksovski
- Ss. Cyril and Methodius University in Skopje, Faculty of Natural Sciences and Mathematics-Skopje, Institute of Biology, Arhimedova 3, PO Box 162, 1000 Skopje, North Macedonia
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Sachan A, Dhibar DP, Bhalla A, Prakash A, Taneja S, Sharma V. COMPARISON OF NON-ENDOSCOPIC SCORES FOR THE PREDICTION OF OUTCOMES IN PATIENTS OF UPPER GASTROINTESTINAL BLEED IN AN EMERGENCY OF A TERTIARY CARE REFERRAL HOSPITAL: A PROSPECTIVE COHORT STUDY. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:534-540. [PMID: 34909862 DOI: 10.1590/s0004-2803.202100000-95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/29/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Traditionally peptic ulcer disease was the most common cause of upper gastrointestinal (UGI) bleed but with the changing epidemiology; other etiologies of UGI bleed are emerging. Many scores have been described for predicting outcomes and the need for intervention in UGI bleed but prospective comparison among them is scarce. OBJECTIVE This study was planned to determine the etiological pattern of UGI bleed and to compare Glasgow Blatchford score, Pre-Endoscopy Rockall score, AIMS65, and Modified Early Warning Score (MEWS) as predictors of outcome. METHODS In this prospective cohort study 268 patients of UGI bleed were enrolled and followed up for 8 weeks. Glasgow Blatchford score, Endoscopy Rockall score, AIMS65, and MEWS were calculated for each patient, and the area under the receiver operating characteristic (AUC-ROC) curve for each score was compared. RESULTS The most common etiology for UGI bleed were gastroesophageal varices 150 (63.55%) followed by peptic ulcer disease 29 (12.28%) and mucosal erosive disease 27 (11.44%). Total 38 (15.26%) patients had re-bleed and 71 (28.5%) patients died. Overall, 126 (47%) patients required blood component transfusion, 25 (9.3%) patients required mechanical ventilation and 2 (0.74%) patients required surgical intervention. Glasgow Blatchford score was the best in predicting the need for transfusion (cut off - 10, AUC-ROC= 0.678). Whereas AIMS65 with a score of ≥2 was best in predicting re-bleed (AUC-ROC=0.626) and mortality (AUC-ROC=0.725). CONCLUSION Gastrointestinal bleed was most commonly of variceal origin at our tertiary referral center in Northern India. AIMS65 was the best & simplest score with a score of ≥2 for predicting re-bleed and mortality.
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Affiliation(s)
- Anurag Sachan
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
| | - Deba Prasad Dhibar
- Post Graduate Institute of Medical Education and Research, Department of Internal Medicine, Chandigarh, India
| | - Ashish Bhalla
- Post Graduate Institute of Medical Education and Research, Department of Internal Medicine, Chandigarh, India
| | - Ajay Prakash
- Post Graduate Institute of Medical Education and Research, Department of Pharmacology, Chandigarh, India
| | - Sunil Taneja
- Post Graduate Institute of Medical Education and Research, Department of Hepatology, Chandigarh, India
| | - Vishal Sharma
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
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4
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Jiang X. An improved modified early warning score that incorporates the abdomen score for identifying multiple traumatic injury severity. PeerJ 2020; 8:e10242. [PMID: 33194421 PMCID: PMC7597630 DOI: 10.7717/peerj.10242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 10/05/2020] [Indexed: 11/20/2022] Open
Abstract
Background Rapid identification of trauma severity is essential for the timely triage of multiple trauma patients. Tools such as the modified early warning score (MEWS) are used for determining injury severity. Although the conventional MEWS is a good predictor of mortality, its performance assessing injury severity is moderate. This study hypothesized that adding an injury site severity-related score (e.g., abdomen score) may enhance the capability of the MEWS for identifying severe trauma. Method To validate the hypothesis, we propose an improved modified early warning score called MEWS-A, which incorporates an injury site-specific severity-related abdomen score to MEWS. The utility of MEWS and MEWS-A were retrospectively evaluated and compared for identifying trauma severity in adult multiple trauma patients admitted to the emergency department. Results We included 1,230 eligible multiple trauma patients and divided them into minor and severe trauma groups based on the injury severity score. Results of logistic regression and receiver operating characteristic (ROC) curve analyses showed that the MEWS-A had a higher area under the ROC curve (AUC: 0.81 95% CI [0.78-0.83]) than did the MEWS (AUC: 0.77 95% CI [0.74-0.79]), indicating that the MEWS-A is superior to the MEWS in identifying severe trauma. The optimal MEWS-A cut-off score is 4, with a specificity of 0.93 and a sensitivity of 0.54. MEWS-A ≥ 4 can be used as a protocol for decision-making in the emergency department. Conclusions Our study suggests that while the conventional MEWS is sufficient for predicting mortality risk, adding an injury site-specific score (e.g., abdomen score) can enhance its performance in determining injury severity in multiple trauma patients.
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Affiliation(s)
- Xiaobin Jiang
- Emergency Department 1, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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5
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Biswas S, Acharyya S, Roy P, Samaddar D, Dasgupta C, Jana D. Efficacy of Chronomodulated Chemotherapy for Palliation of Hematemesis in Inoperable Gastric Cancer: A Single-Institutional Retrospective Study. Indian J Palliat Care 2020; 26:342-347. [PMID: 33311877 PMCID: PMC7725184 DOI: 10.4103/ijpc.ijpc_201_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/14/2020] [Indexed: 12/24/2022] Open
Abstract
Context: Aside abdominal discomfort and pain, upper gastrointestinal bleeding (UGIB) significantly disgraces the quality of life (QoL), especially in inoperable gastric cancer patients. Although, in early stages, it is infrequent and often ignored, but in advanced stages, its aggressiveness often deteriorates patient's hemoglobin (Hb) level and performing status. Aim: The aim of this study is to correlate the change in (1) the frequency of episodes of UGIB, (2) its severity in terms of Common Terminology Criteria for Adverse Events (CTCAE) grade for UGIB, and (3) Hb level with the successful completion of successive cycles of palliative chemotherapy where it becomes invariably the only modality to palliate the cancer disease. Setting and Design: This single-institutional retrospective observational study included seventy gastric carcinoma patients with a chief complaint of frequent hematemesis. They were divided according to the cause behind inoperability or irresectability: (1) Metastatic disease, (2) locally advanced irresectable disease, (3) uncontrolled comorbidities, (4) poor GC (PGC), and (5) refused to give surgical consent. Subjects and Methods: Following baseline evaluation and prechemotherapy workups, patients were subjected to three-weekly chronomodulated modified EOX regimen. Relevant parameters, i.e., (1) average episodes per-week (AEP) score, (2) Hb, and (3) average CTCAE grade value for UGIB were recorded after every cycle. Results: At 12-week follow-up, there was a significant decrease in mean AEP score from baseline (from 2.6691 ± 0.7047 to 1.5033 ± 0.6272) for the entire cohort (P < 0.001). Maximum benefit in terms of mean Hb (increase by 1.0737% above baseline) took place for PGC group (P < 0.001). Mean CTCAE grade value for the entire cohort decreased from baseline by 0.6428, which was statistically significant with a P < 0.001. Conclusions: PGC group was maximally benefited considering all three parameters. Though surgery defines the mainstay of treatment for gastric carcinoma, yet in inoperable cases, only chronomodulated chemotherapy significantly affects the severity of UGIB and thus may improve QoL.
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Affiliation(s)
- Satadru Biswas
- Department of Radiotherapy, R G Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Santanu Acharyya
- Department of Radiotherapy, R G Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Pritha Roy
- Department of Radiotherapy, R G Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Debdeep Samaddar
- Department of Radiotherapy, R G Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Chandan Dasgupta
- Department of Radiotherapy, R G Kar Medical College and Hospital, Kolkata, West Bengal, India
| | - Debarshi Jana
- Department of Gynecology and Obstetrics, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India
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Siau K, Hearnshaw S, Stanley AJ, Estcourt L, Rasheed A, Walden A, Thoufeeq M, Donnelly M, Drummond R, Veitch AM, Ishaq S, Morris AJ. British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding. Frontline Gastroenterol 2020; 11:311-323. [PMID: 32582423 PMCID: PMC7307267 DOI: 10.1136/flgastro-2019-101395] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Medical care bundles improve standards of care and patient outcomes. Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency which has been consistently associated with suboptimal care. We aimed to develop a multisociety care bundle centred on the early management of AUGIB. Commissioned by the British Society of Gastroenterology (BSG), a UK multisociety task force was assembled to produce an evidence-based and consensus-based care bundle detailing key interventions to be performed within 24 hours of presentation with AUGIB. A modified Delphi process was conducted with stakeholder representation from BSG, Association of Upper Gastrointestinal Surgeons, Society for Acute Medicine and the National Blood Transfusion Service of the UK. A formal literature search was conducted and international AUGIB guidelines reviewed. Evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation tool and statements were formulated and subjected to anonymous electronic voting to achieve consensus. Accepted statements were eligible for incorporation into the final bundle after a separate round of voting. The final version of the care bundle was reviewed by the BSG Clinical Services and Standards Committee and approved by all stakeholder groups. Consensus was reached on 19 statements; these culminated in 14 corresponding care bundle items, contained within 6 management domains: Recognition, Resuscitation, Risk assessment, Rx (Treatment), Refer and Review. A multisociety care bundle for AUGIB has been developed to facilitate timely delivery of evidence-based interventions and drive quality improvement and patient outcomes in AUGIB.
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Affiliation(s)
- Keith Siau
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK,Medical and Dental Sciences, University of Birmingham, Birmingham, UK,Endoscopy Unit, Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK
| | - Sarah Hearnshaw
- Department of Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Ashraf Rasheed
- Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, London, UK,Upper GI Surgery, Royal Gwent Hospital, Newport, UK
| | - Andrew Walden
- Society for Acute Medicine, London, UK,Intensive Care Unit, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Mo Thoufeeq
- Endoscopy Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mhairi Donnelly
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Russell Drummond
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Andrew M Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Sauid Ishaq
- Endoscopy Unit, Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK,School of Health Sciences, Birmingham City University, Birmingham, West Midlands, UK
| | - Allan John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK,Endoscopy Quality Improvement Programme (EQIP), British Society of Gastroenterology, London, UK
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Jono F, Iida H, Fujita K, Kaai M, Kanoshima K, Ohkuma K, Nonaka T, Ida T, Kusakabe A, Nakamura A, Koyama S, Nakajima A, Inamori M. Comparison of computed tomography findings with clinical risks factors for endoscopic therapy in upper gastrointestinal bleeding cases. J Clin Biochem Nutr 2019; 65:138-145. [PMID: 31592208 DOI: 10.3164/jcbn.18-115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/16/2019] [Indexed: 12/14/2022] Open
Abstract
Several risk scoring systems exist for acute upper gastrointestinal bleeding (UGIB). The clinical Rockall score (clinical RS) and the Glasgow-Blatchford score (GBS) are major risk scores that consider only clinical data. Computed tomography (CT) findings are equivocal in non-variceal UGIB. We compared CT findings with clinical data to predict mortality, rebleeding and need for endoscopic therapy in non-variceal UGIB patients. This retrospective, single-center study included 386 patients admitted to our emergency department with diagnosis of non-variceal UGIB by urgent endoscopy between January 2009 and March 2015. Multivariable logistic regression analysis was used to investigate CT findings and risk factors derived from clinical data. CT findings could not significantly predict mortality and rebleeding in non-variceal UGIB patients. However, upper gastrointestinal hemorrhage in CT findings better predicted the need for endoscopic therapy than clinical data. The adjusted odds ratios were 10.10 (95% CI 5.01-20.40) for clinical RS and 10.70 (95% CI 5.08-22.70) for the GBS. UGI hemorrhage in CT findings could predict the need for endoscopic therapy in non-variceal UGIB patients in our emergency department. CT findings as well as risk score systems may be useful for predicting the need for endoscopic therapy.
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Affiliation(s)
- Fumitake Jono
- Department of Medical Education, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hiroshi Iida
- Department of Hepatology and Gastroenterology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Koji Fujita
- Office of Postgraduate Medical Education, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Megumi Kaai
- Yokohama Hodogaya Central Hospital, 43-1, Kamadai-cho, Hodogaya-ku, Yokohama 240-8585, Japan
| | - Kenji Kanoshima
- Department of Hepatology and Gastroenterology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Kanji Ohkuma
- Department of Hepatology and Gastroenterology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Takashi Nonaka
- Department of Hepatology and Gastroenterology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Tomonori Ida
- Department of Medical Education, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Akihiko Kusakabe
- Office of Postgraduate Medical Education, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Atsushi Nakamura
- Department of Endoscopy and Gastroenterology, Tokyo Metropolitan Hiroo Hospital, 2-34-10 Ebisu, Shibuya-ku, Tokyo 150-0013, Japan
| | - Shigeru Koyama
- Department of Endoscopy and Gastroenterology, Tokyo Metropolitan Hiroo Hospital, 2-34-10 Ebisu, Shibuya-ku, Tokyo 150-0013, Japan
| | - Atsushi Nakajima
- Department of Hepatology and Gastroenterology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Masahiko Inamori
- Department of Medical Education, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
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Lee DH, Lee KM, Lee SM, Lee BK, Cho YS, Choi G, Yun SW. Performance of Three Scoring Systems in Predicting Massive Transfusion in Patients with Unstable Upper Gastrointestinal Hemorrhage. Yonsei Med J 2019; 60:368-374. [PMID: 30900423 PMCID: PMC6433562 DOI: 10.3349/ymj.2019.60.4.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/29/2019] [Accepted: 02/20/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE After trauma and surgery, upper gastrointestinal bleeding (UGIB) is the most common condition that can require massive transfusion (MT). The present study aimed to analyze and compare the prognostic performance of the Glasgow-Blatchford (GB), pre-endoscopy Rockall (PER), and modified early warning (MEW) scores for predicting MT in patients with unstable UGIB. MATERIALS AND METHODS This retrospective observational study included patients with UGIB from March 2016 to February 2018. Receiver operating characteristics analysis was performed to examine the prognostic performance of the GB, PER, and MEW scoring systems. Logistic regression analysis was used to identify independent risk factors for MT, after adjusting for relevant covariates. The primary outcome was MT. RESULTS Of the 484 included patients with unstable UGIB, 19 (3.9%) received an MT. The areas under the curves (AUCs) of the GB, PER, and MEW scores for MT were 0.577 [95% confidence interval (CI), 0.531-0.621], 0.570 (95% CI, 0.525-0.615), and 0.767 (95% CI, 0.727-0.804), respectively. The AUC of the MEW score was significantly different from those of the GB and PER scores. In multivariate analysis, MEW score was independently associated with MT in patients with unstable UGIB (odds ratio, 1.495; 95% CI, 1.100-2.033; p=0.010). CONCLUSION In unstable UGIB patients, MEW score had the best prognostic performance for MT among three scoring systems.
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Affiliation(s)
- Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Kyeung Mi Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sung Min Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea.
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Goeun Choi
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Seong Woo Yun
- Department of Emergency Medical Technology, Namseoul University, Cheonan, Korea
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Kim WY, Lee J, Lee JR, Jung YK, Kim HJ, Huh JW, Lim CM, Koh Y, Hong SB. A risk scoring model based on vital signs and laboratory data predicting transfer to the intensive care unit of patients admitted to gastroenterology wards. J Crit Care 2017; 40:213-217. [PMID: 28445859 DOI: 10.1016/j.jcrc.2017.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 03/09/2017] [Accepted: 04/14/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE To compare the ability of a score based on vital signs and laboratory data with that of the modified early warning score (MEWS) to predict ICU transfer of patients with gastrointestinal disorders. MATERIALS AND METHODS Consecutive events triggering medical emergency team activation in adult patients admitted to the gastroenterology wards of the Asan Medical Center were reviewed. Binary logistic regression was used to identify factors predicting transfer to the ICU. Gastrointestinal early warning score (EWS-GI) was calculated as the sum of simplified regression weights (SRW). RESULTS Of the 1219 included patients, 468 (38%) were transferred to the ICU. Multivariate analysis identified heart rate≥105bpm (SRW 1), respiratory rate≥26bpm (SRW 2), ACDU (Alert, Confused, Drowsy, Unresponsive) score≥1 (SRW 2), SpO2/FiO2 ratio<240 (SRW 2), creatinine ≥2.0mg/dL (SRW 2), total bilirubin ≥9.0mg/dL (SRW 2), prothrombin time/international normalized ratio (INR) ≥1.5 (SRW 2), and lactate ≥3.0mmol/L (SRW 2) for inclusion in EWS-GI. The area under the receiver operating characteristic curve of the EWS-GI was larger than that of MEWS (0.76 vs. 0.64; P<0.001). CONCLUSIONS EWS-GI may predict ICU transfer among patients admitted to gastroenterology wards. The EWS-GI should be prospectively validated.
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Affiliation(s)
- Won-Young Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Jinmi Lee
- Medical Emergency Team, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Ju-Ry Lee
- Medical Emergency Team, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Youn Kyung Jung
- Medical Emergency Team, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Republic of Korea.
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-Gil, Songpa-gu, Seoul 05505, Republic of Korea.
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10
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Murray IA, Dalton HR, Stanley AJ, Ngu JH, Maybin B, Eid M, Madsen KG, Abazi R, Ashraf H, Abdelrahim M, Lissmann R, Herrod J, Khor CJ, Ong HS, Koay DS, Chin YK, Laursen SB. International prospective observational study of upper gastrointestinal haemorrhage: Does weekend admission affect outcome? United European Gastroenterol J 2017; 5:1082-1089. [PMID: 29238586 DOI: 10.1177/2050640617700984] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/26/2017] [Indexed: 01/06/2023] Open
Abstract
Introduction Out of hours admissions have higher mortality for many conditions but upper gastrointestinal haemorrhage studies have produced variable outcomes. Methods Prospective study of 12 months consecutive admissions of upper gastrointestinal haemorrhage from four international high volume centres. Admission period (weekdays, weeknights or weekends), demographics, haemodynamic parameters, laboratory results, endoscopy findings, further procedures and 30-day mortality were recorded. Five upper gastrointestinal haemorrhage risk scores were calculated. Results 2118 patients, 60% male, median age 66 years were studied. Compared with patients presenting on weekdays, patients presenting at weekends had no significant differences in comorbidity, pulse, systolic BP, risk scores, frequency of peptic ulcers or varices. Those presenting on weekdays had lower haemoglobin (p = 0.007) and were more likely to have a normal endoscopy (p < 0.01). Time to endoscopy was less for weeknight presentation (p = 0.001). Sixty-seven per cent of those presenting on weekdays, 75% on weeknights and 60% at weekends had endoscopy within 24 h. Transfusion requirements, need for endoscopic therapy or surgery/embolization, rebleeding rates (6.1%) and mortality (7.2%) did not differ with presentation time. Conclusion This multi-centre international study in large centres found no difference in demographics, comorbidity or haemodynamic stability and no increase in mortality for patients presenting with upper gastrointestinal haemorrhage out of hours.
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Affiliation(s)
- Iain A Murray
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
| | - Harry R Dalton
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Jing H Ngu
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Brian Maybin
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Mahmoud Eid
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Kenneth G Madsen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Rozeta Abazi
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Hamad Ashraf
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
| | | | - Rebecca Lissmann
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
| | - Jenny Herrod
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
| | - Christopher Jl Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Hock S Ong
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Doreen Sc Koay
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Yung K Chin
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
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11
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Zhong M, Chen WJ, Lu XY, Qian J, Zhu CQ. Comparison of three scoring systems in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding: a prospective observational study. J Dig Dis 2016; 17:820-828. [PMID: 27930875 DOI: 10.1111/1751-2980.12433] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/23/2016] [Accepted: 12/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare the performances of the Glasgow-Blatchford score (GBS), modified GBS (mGBS) and AIMS65 in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding (AUGIB). METHODS This study enrolled 320 consecutive patients with AUGIB. Patients at high and low risks of developing adverse clinical outcomes (rebleeding, the need of clinical intervention and death) were categorized according to the GBS, mGBS and AIMS65 scoring systems. The outcome of the patients were the occurrences of adverse clinical outcomes. The areas under the receiver operating characteristics curve (AUROC) of three scoring systems were compared. RESULTS Irrespective of the systems used, the high-risk groups showed higher rates of rebleeding, intervention and death compared with the low-risk groups (P < 0.05). For the prediction of rebleeding, AIMS65 (AUROC 0.735, 95% CI 0.667-0.802) performed significantly better than GBS (AUROC 0.672, 95% CI 0.597-0.747; P < 0.01) and mGBS (AUROC 0.677, 95% CI 0.602-0.753; P < 0.01). For the prediction of interventions, there was no significant difference among the three systems (GBS: AUROC 0.769, 95% CI 0.668-0.870; mGBS: AUROC 0.745, 95% CI 0.643-0.847; AIMS65: AUROC 0.746, 95% CI 0.640-0.851). For the prediction of in-hospital mortality, there was no significant difference among the three systems (GBS: AUROC 0.796, 95% CI 0.694-0.898; mGBS: AUROC 0.803, 95% CI 0.703-0.904; AIMS65: AUROC 0.786, 95% CI 0.670-0.903). CONCLUSIONS The three scoring systems are reliable and accurate in predicting the rates of rebleeding, surgery and mortality in AUGIB. However, AIMS65 outperforms GBS and mGBS in predicting rebleeding.
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Affiliation(s)
- Min Zhong
- Department of Emergency Medicine, Renjii Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Wan Jun Chen
- Department of Emergency Medicine, Renjii Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao Ye Lu
- Department of Emergency Medicine, Renjii Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jie Qian
- Department of Emergency Medicine, Renjii Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Chang Qing Zhu
- Department of Emergency Medicine, Renjii Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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12
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Mokhtare M, Bozorgi V, Agah S, Nikkhah M, Faghihi A, Boghratian A, Shalbaf N, Khanlari A, Seifmanesh H. Comparison of Glasgow-Blatchford score and full Rockall score systems to predict clinical outcomes in patients with upper gastrointestinal bleeding. Clin Exp Gastroenterol 2016; 9:337-343. [PMID: 27826205 PMCID: PMC5096755 DOI: 10.2147/ceg.s114860] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Various risk scoring systems have been recently developed to predict clinical outcomes in patients with upper gastrointestinal bleeding (UGIB). The two commonly used scoring systems include full Rockall score (RS) and the Glasgow-Blatchford score (GBS). Bleeding scores were assessed in terms of prediction of clinical outcomes in patients with UGIB. Patients and methods Two hundred patients (age >18 years) with obvious symptoms of UGIB in the emergency department of Rasoul Akram Hospital were enrolled. Full RS and GBS were calculated. We followed the patients for records of rebleeding and 1-month mortality. A receiver operating characteristic curve by using areas under the curve (AUCs) was used to statistically identify the best cutoff point. Results Eighteen patients were excluded from the study due to failure to follow-up. Rebleeding and mortality rate were 9.34% (n=17) and 11.53% (n=21), respectively. Regarding 1-month mortality, full RS was better than GBS (AUC, 0.648 versus 0.582; P=0.021). GBS was more accurate in terms of detecting transfusion need (AUC, 0.757 versus 0.528; P=0.001), rebleeding rate (AUC, 0.722 versus 0.520; P=0.002), intensive care unit admission rate (AUC, 0.648 versus 0.582; P=0.021), and endoscopic intervention rate (AUC, 0.771 versus 0.650; P<0.001). Conclusion We found the full RS system is better for 1-month mortality prediction while GBS system is better for prediction of other outcomes.
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Affiliation(s)
- Marjan Mokhtare
- Colorectal Research Center, Rasoul Akram Hospital, Tehran, Iran
| | - Vida Bozorgi
- Colorectal Research Center, Rasoul Akram Hospital, Tehran, Iran
| | - Shahram Agah
- Colorectal Research Center, Rasoul Akram Hospital, Tehran, Iran
| | - Mehdi Nikkhah
- Colorectal Research Center, Rasoul Akram Hospital, Tehran, Iran
| | | | | | - Neda Shalbaf
- Colorectal Research Center, Rasoul Akram Hospital, Tehran, Iran
| | - Abbas Khanlari
- Colorectal Research Center, Rasoul Akram Hospital, Tehran, Iran
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13
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Tomizawa M, Shinozaki F, Hasegawa R, Shirai Y, Motoyoshi Y, Sugiyama T, Yamamoto S, Ishige N. Change ratio of hemoglobin has predictive value for upper gastrointestinal bleeding. Biomed Rep 2016; 5:479-482. [PMID: 27699017 DOI: 10.3892/br.2016.753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/25/2016] [Indexed: 12/26/2022] Open
Abstract
The present study aimed to identify novel predictors of upper gastrointestinal (GI) bleeding by assessing change ratios of blood test variables. Records of 1,023 patients (431 men and 592 women) who underwent endoscopy between October 2014 and September 2015 at the National Hospital Organization Shimoshizu Hospital (Yotsukaido, Japan) were retrospectively analyzed. Patients whose blood test variables for the time-point of endoscopy and three months previously were available were enrolled and subsequently categorized into a group with and another one without upper GI bleeding (n=32 and 84, respectively), and the respective change ratios were calculated for each group. One-way analysis of variance revealed that in patients with upper GI bleeding, change ratios of white blood cell count and alkaline phosphatase were significantly higher than those in patients without, while change ratios of hemoglobin (Hb), total protein and albumin were significantly reduced. Logistic regression analysis demonstrated that the change ratio of Hb was significantly correlated with upper GI bleeding. Receiver-operator characteristic analysis revealed that an 18.7% reduction of Hb was the threshold value for the prediction of upper GI bleeding. In conclusion, the present study revealed that a ≥18.7% reduction in Hb over three months has predictive value for upper GI bleeding.
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Affiliation(s)
- Minoru Tomizawa
- Department of Gastroenterology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Fuminobu Shinozaki
- Department of Radiology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Rumiko Hasegawa
- Department of Surgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Yoshinori Shirai
- Department of Surgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Yasufumi Motoyoshi
- Department of Neurology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Takao Sugiyama
- Department of Rheumatology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Shigenori Yamamoto
- Department of Pediatrics, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Naoki Ishige
- Department of Neurosurgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
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14
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Tomizawa M, Shinozaki F, Hasegawa R, Shirai Y, Motoyoshi Y, Sugiyama T, Yamamoto S, Ishige N. Low hemoglobin levels are associated with upper gastrointestinal bleeding. Biomed Rep 2016; 5:349-352. [PMID: 27588176 DOI: 10.3892/br.2016.727] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/17/2016] [Indexed: 12/22/2022] Open
Abstract
Upper gastrointestinal (GI) bleeding can be fatal. Blood test variables were reviewed in search of threshold values to detect the presence of occult upper GI bleeding. The records of 1,023 patients who underwent endoscopy at the National Hospital Organization Shimoshizu Hospital from October 2014, to September 2015, were retrospectively reviewed. Of those, 95 had upper GI bleeding. One-way analysis of variance was applied to blood test variables comparing patients with and without upper GI bleeding. Logistic regression analysis was applied to detect the association of blood test parameters with upper GI bleeding, and receiver-operator characteristics were applied to establish threshold values. White blood cell count (WBC), platelet (Plt) count, and blood urea nitrogen (BUN) levels were higher, and hemoglobin (Hb) and albumin (Alb) levels were lower in patients with upper GI bleeding. Logistic regression analysis showed that low Hb was significantly associated with upper GI bleeding and a Hb value of 10.8 g/dl was established as the threshold for the diagnosis. In patients with upper GI bleeding, WBC, Plt count, and BUN levels were higher and Hb and Alb levels were reduced. Hb at 10.8 g/dl was established as a threshold value to detect upper GI bleeding.
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Affiliation(s)
- Minoru Tomizawa
- Department of Gastroenterology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Fuminobu Shinozaki
- Department of Radiology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Rumiko Hasegawa
- Department of Surgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Yoshinori Shirai
- Department of Surgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Yasufumi Motoyoshi
- Department of Neurology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Takao Sugiyama
- Department of Rheumatology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Shigenori Yamamoto
- Department of Pediatrics, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Naoki Ishige
- Department of Neurosurgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
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15
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Sano H, Tsurukiri J, Hoshiai A, Oomura T, Tanaka Y, Ohta S. Resuscitative endovascular balloon occlusion of the aorta for uncontrollable nonvariceal upper gastrointestinal bleeding. World J Emerg Surg 2016; 11:20. [PMID: 27213011 PMCID: PMC4875689 DOI: 10.1186/s13017-016-0076-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 05/10/2016] [Indexed: 12/02/2022] Open
Abstract
Background Although resuscitative endovascular balloon occlusion of the aorta (REBOA) in various clinical settings was found to successfully elevate central blood pressure in hemorrhagic shock, this intervention is associated with high mortality and may represent a last-ditch option for trauma patients. We conducted a retrospective study of patients with nonvariceal upper gastrointestinal bleeding (UGIB) who underwent REBOA to identify the effectiveness of REBOA and reviewed published literatures. Methods REBOA were performed by trained acute care physicians in the emergency room and intensive care unit. The deployment of balloon catheters was positioned using ultrasonography guidance. Collected data included clinical characteristics, hemorrhagic severity, blood cultures, metabolic values, blood transfusions, REBOA-related complications and mortality. A literature search using PUBMED to include “aortic occlusion” and “gastrointestinal bleeding” was conducted. Results REBOA was attempted in eight patients among 140 patients with UGIB and median age was 66 years. Systolic blood pressure significantly increased after REBOA (66 ± 20 vs. 117 ± 45 mmHg, p < 0.01) and the total occlusion time of REBOA was 80 ± 48 min. Strong positive correlations were found between total occlusion time of REBOA and lactate concentration (Spearman’s r=0.77), clinical Rockwall score (Spearman’s r=0.80), and age (Spearman’s r=0.88), respectively. Conclusion REBOA can be performed with a high degree of technical success and is effective at improving hemodynamic in patients with UGIB. Correlations between total occlusion time and high lactate levels, clinical Rockall score, and age may be important for successful use of REBOA.
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Affiliation(s)
- Hidefumi Sano
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998 Japan
| | - Junya Tsurukiri
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998 Japan
| | - Akira Hoshiai
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998 Japan
| | - Taishi Oomura
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998 Japan
| | - Yosuke Tanaka
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998 Japan
| | - Shoichi Ohta
- Emergency and Disaster Medicine, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku, Tokyo, 160-0023 Japan
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